Healthcare Provider Details

I. General information

NPI: 1801198510
Provider Name (Legal Business Name): POTTER FAMILY EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5953 W BROADWAY
MC CORDSVILLE IN
46055-9355
US

IV. Provider business mailing address

5953 W BROADWAY
MC CORDSVILLE IN
46055-9355
US

V. Phone/Fax

Practice location:
  • Phone: 317-747-9263
  • Fax: 317-747-9271
Mailing address:
  • Phone: 317-747-9263
  • Fax: 317-747-9271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003358A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18003358A
License Number StateIN

VIII. Authorized Official

Name: DR. AUSTIN POTTER
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 317-747-9263